<?php
session_start ();
$_SESSION ['pathway'] = '..';
include ("../header.php");

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	echo "<table class='principale'><tr><td>Session expired</td></tr>";
	echo "<tr><td><a href='" . $_SESSION ['pathway'] . "/index.php'>Start</a></td></tr></table>";
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	?><a href="<?php echo $_SESSION['pathway']; ?>/index.php">Start</a>
>
<a href="<?php echo $_SESSION['pathway']; ?>/authok.php">Home</a>
>
<a
	href="./page_principale.php?form=<?php echo $_SESSION['form'];?>#annexes">Form <?php echo $_SESSION['form'];?></a>
> SPRS 
	<?php
	
	require ("./requetes/remplissage_questionnaire_SPRS.php");
	// print_r($hash_champ_SPRS);
	
	if ($hash_champ_SPRS ['walk'] == '0') {
		$check_walk_zero = 'checked';
	} elseif ($hash_champ_SPRS ['walk'] == '1') {
		$check_walk_un = 'checked';
	} elseif ($hash_champ_SPRS ['walk'] == '2') {
		$check_walk_deux = 'checked';
	} elseif ($hash_champ_SPRS ['walk'] == '3') {
		$check_walk_trois = 'checked';
	} elseif ($hash_champ_SPRS ['walk'] == '4') {
		$check_walk_quatre = 'checked';
	}
	
	if ($hash_champ_SPRS ['gait'] == '0') {
		$check_gait_zero = 'checked';
	} elseif ($hash_champ_SPRS ['gait'] == '1') {
		$check_gait_un = 'checked';
	} elseif ($hash_champ_SPRS ['gait'] == '2') {
		$check_gait_deux = 'checked';
	} elseif ($hash_champ_SPRS ['gait'] == '3') {
		$check_gait_trois = 'checked';
	} elseif ($hash_champ_SPRS ['gait'] == '4') {
		$check_gait_quatre = 'checked';
	}
	if ($hash_champ_SPRS ['gait_speed'] == '0') {
		$check_gait_speed_zero = 'checked';
	} elseif ($hash_champ_SPRS ['gait_speed'] == '1') {
		$check_gait_speed_un = 'checked';
	} elseif ($hash_champ_SPRS ['gait_speed'] == '2') {
		$check_gait_speed_deux = 'checked';
	} elseif ($hash_champ_SPRS ['gait_speed'] == '3') {
		$check_gait_speed_trois = 'checked';
	} elseif ($hash_champ_SPRS ['gait_speed'] == '4') {
		$check_gait_speed_quatre = 'checked';
	}
	
	if ($hash_champ_SPRS ['climb'] == '0') {
		$check_climb_zero = 'checked';
	} elseif ($hash_champ_SPRS ['climb'] == '1') {
		$check_climb_un = 'checked';
	} elseif ($hash_champ_SPRS ['climb'] == '2') {
		$check_climb_deux = 'checked';
	} elseif ($hash_champ_SPRS ['climb'] == '3') {
		$check_climb_trois = 'checked';
	} elseif ($hash_champ_SPRS ['climb'] == '4') {
		$check_climb_quatre = 'checked';
	}
	
	if ($hash_champ_SPRS ['climb_speed'] == '0') {
		$check_climb_speed_zero = 'checked';
	} elseif ($hash_champ_SPRS ['climb_speed'] == '1') {
		$check_climb_speed_un = 'checked';
	} elseif ($hash_champ_SPRS ['climb_speed'] == '2') {
		$check_climb_speed_deux = 'checked';
	} elseif ($hash_champ_SPRS ['climb_speed'] == '3') {
		$check_climb_speed_trois = 'checked';
	} elseif ($hash_champ_SPRS ['climb_speed'] == '4') {
		$check_climb_speed_quatre = 'checked';
	}
	
	if ($hash_champ_SPRS ['rise'] == '0') {
		$check_rise_zero = 'checked';
	} elseif ($hash_champ_SPRS ['rise'] == '1') {
		$check_rise_un = 'checked';
	} elseif ($hash_champ_SPRS ['rise'] == '2') {
		$check_rise_deux = 'checked';
	} elseif ($hash_champ_SPRS ['rise'] == '3') {
		$check_rise_trois = 'checked';
	} elseif ($hash_champ_SPRS ['rise'] == '4') {
		$check_rise_quatre = 'checked';
	}
	if ($hash_champ_SPRS ['spas_hip'] == '0') {
		$check_spas_hip_zero = 'checked';
	} elseif ($hash_champ_SPRS ['spas_hip'] == '1') {
		$check_spas_hip_un = 'checked';
	} elseif ($hash_champ_SPRS ['spas_hip'] == '2') {
		$check_spas_hip_deux = 'checked';
	} elseif ($hash_champ_SPRS ['spas_hip'] == '3') {
		$check_spas_hip_trois = 'checked';
	} elseif ($hash_champ_SPRS ['spas_hip'] == '4') {
		$check_spas_hip_quatre = 'checked';
	}
	
	if ($hash_champ_SPRS ['spas_knee'] == '0') {
		$check_spas_knee_zero = 'checked';
	} elseif ($hash_champ_SPRS ['spas_knee'] == '1') {
		$check_spas_knee_un = 'checked';
	} elseif ($hash_champ_SPRS ['spas_knee'] == '2') {
		$check_spas_knee_deux = 'checked';
	} elseif ($hash_champ_SPRS ['spas_knee'] == '3') {
		$check_spas_knee_trois = 'checked';
	} elseif ($hash_champ_SPRS ['spas_knee'] == '4') {
		$check_spas_knee_quatre = 'checked';
	}
	if ($hash_champ_SPRS ['weakness_hip'] == '0') {
		$check_weakness_hip_zero = 'checked';
	} elseif ($hash_champ_SPRS ['weakness_hip'] == '1') {
		$check_weakness_hip_un = 'checked';
	} elseif ($hash_champ_SPRS ['weakness_hip'] == '2') {
		$check_weakness_hip_deux = 'checked';
	} elseif ($hash_champ_SPRS ['weakness_hip'] == '3') {
		$check_weakness_hip_trois = 'checked';
	} elseif ($hash_champ_SPRS ['weakness_hip'] == '4') {
		$check_weakness_hip_quatre = 'checked';
	}
	
	if ($hash_champ_SPRS ['weakness_foot'] == '0') {
		$check_weakness_foot_zero = 'checked';
	} elseif ($hash_champ_SPRS ['weakness_foot'] == '1') {
		$check_weakness_foot_un = 'checked';
	} elseif ($hash_champ_SPRS ['weakness_foot'] == '2') {
		$check_weakness_foot_deux = 'checked';
	} elseif ($hash_champ_SPRS ['weakness_foot'] == '3') {
		$check_weakness_foot_trois = 'checked';
	} elseif ($hash_champ_SPRS ['weakness_foot'] == '4') {
		$check_weakness_foot_quatre = 'checked';
	}
	if ($hash_champ_SPRS ['lowerlimbs'] == '0') {
		$check_lowerlimbs_zero = 'checked';
	} elseif ($hash_champ_SPRS ['lowerlimbs'] == '1') {
		$check_lowerlimbs_un = 'checked';
	} elseif ($hash_champ_SPRS ['lowerlimbs'] == '2') {
		$check_lowerlimbs_deux = 'checked';
	} elseif ($hash_champ_SPRS ['lowerlimbs'] == '3') {
		$check_lowerlimbs_trois = 'checked';
	} elseif ($hash_champ_SPRS ['lowerlimbs'] == '4') {
		$check_lowerlimbs_quatre = 'checked';
	}
	
	if ($hash_champ_SPRS ['relatedsymptoms'] == '0') {
		$check_relatedsymptoms_zero = 'checked';
	} elseif ($hash_champ_SPRS ['relatedsymptoms'] == '1') {
		$check_relatedsymptoms_un = 'checked';
	} elseif ($hash_champ_SPRS ['relatedsymptoms'] == '2') {
		$check_relatedsymptoms_deux = 'checked';
	} elseif ($hash_champ_SPRS ['relatedsymptoms'] == '3') {
		$check_relatedsymptoms_trois = 'checked';
	} elseif ($hash_champ_SPRS ['relatedsymptoms'] == '4') {
		$check_relatedsymptoms_quatre = 'checked';
	}
	if ($hash_champ_SPRS ['BBfunction'] == '0') {
		$check_BBfunction_zero = 'checked';
	} elseif ($hash_champ_SPRS ['BBfunction'] == '1') {
		$check_BBfunction_un = 'checked';
	} elseif ($hash_champ_SPRS ['BBfunction'] == '2') {
		$check_BBfunction_deux = 'checked';
	} elseif ($hash_champ_SPRS ['BBfunction'] == '3') {
		$check_BBfunction_trois = 'checked';
	} elseif ($hash_champ_SPRS ['BBfunction'] == '4') {
		$check_BBfunction_quatre = 'checked';
	}
	
	?>


<form name='frm_srps'
	action='page_principale.php?form=<?php echo $_SESSION['form']; ?>&amp;from=sprs#annexes'
	method='post'>

	<table class='principale'>
		<tr>
			<td><h2>ANNEX 1&#58; Spastic Paraplegia Rating Scale &#40;SPRS&#41;</h2></td>
		</tr>

		<tr>
			<td><br> <b>1&#41; Walking distance without pause <br />Due to
					history, walking aids allowed
			</b></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='walk'
					<?php echo $check_walk_zero ?> value='0' />0&#58; Normal, unlimited
			</label></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='walk'
					<?php echo $check_walk_un ?> value='1' />1&#58; Abnormal exhaustion
					due to spasticity after more than 500m </label></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='walk'
					<?php echo $check_walk_deux ?> value='2' />2&#58; Walking distance
					less than 500m </label></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='walk'
					<?php echo $check_walk_trois ?> value='3' />3&#58; Walking distance
					less than 10 m </label></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='walk'
					<?php echo $check_walk_quatre ?> value='4' />4&#58; Unable to walk
			</label></td>
		</tr>

		<tr>
			<td><br> <b>2&#41; Gait quality <br />Patient is asked to walk as
					fast as possible a 10 meter distance including one turn
			</b></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='gait'
					<?php echo $check_gait_zero ?> value='0' />0&#58; Normal </label></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='gait'
					<?php echo $check_gait_un ?> value='1' />1&#58; Mild stiffness,
					running still possible </label></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='gait'
					<?php echo $check_gait_deux ?> value='2' />2&#58; Clearly spastic
					gait, interfering with running </label></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='gait'
					<?php echo $check_gait_trois ?> value='3' />3&#58; Spastic gait
					requiring use of canes/walker </label></td>
		</tr>
		<tr>
			<td><label><input type='radio' name='gait'
					<?php echo $check_gait_quatre ?> value='4' />4&#58; Unable to walk
					for a 10 meter distance even with maximal support </label></td>
		</tr>

		<tr>
			<td><br> <b>3&#41; Maximum gait speed <br />Time for a 10 meter
					distance including one turn, taken by stop watch Timing&#58;
					<tr>
						<td><label><input type='radio' name='gait_speed'
								<?php echo $check_gait_speed_zero ?> value='0' />0&#58; Normal </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='gait_speed'
								<?php echo $check_gait_speed_un ?> value='1' />1&#58; Slightly
								reduced &#40;10m&#58; &ge; 5s&#41; </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='gait_speed'
								<?php echo $check_gait_speed_deux ?> value='2' />2&#58;
								Moderately reduced &#40;10m&#58; &ge; 10s&#41; </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='gait_speed'
								<?php echo $check_gait_speed_trois ?> value='3' />3&#58;
								Severely reduced &#40;10m&#58; &ge; 20s&#41; </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='gait_speed'
								<?php echo $check_gait_speed_quatre ?> value='4' />4&#58; Unable
								to walk for a 10m distance or time &ge; 40s </label></td>
					</tr> <!--<tr><td>Timing : <input type="text" style="width:40px;" name="gait_timing" value=""></td></tr>-->

					<tr>
						<td><br> <b>4&#41; Climbing stairs <br />5 steps upstairs &minus;
								turn &minus; 5 steps downstairs
						</b></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb'
								<?php echo $check_climb_zero ?> value='0' />0&#58; Normal&#58;
								needs no support of the banister </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb'
								<?php echo $check_climb_un ?> value='1' />1&#58; Mild
								impairment&#58; needs intermittent support of the banister </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb'
								<?php echo $check_climb_deux ?> value='2' />2&#58; Moderate
								impairment&#58; needs permanent support of the banister </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb'
								<?php echo $check_climb_trois ?> value='3' />3&#58; Severe
								impairment&#58; needs support of another person or additional
								walking aid to perform task </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb'
								<?php echo $check_climb_quatre ?> value='4' />4&#58; Unable to
								climb stairs </label></td>
					</tr>

					<tr>
						<td><br> <b>5&#41; Speed of stair climbing <br />Time for 5 steps
								upstairs &minus; turn &minus; 5 steps downstairs, taken by
								stop&minus;watch Timing&#58;
						</b></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb_speed'
								<?php echo $check_climb_speed_zero ?> value='0' />0&#58; Normal
						</label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb_speed'
								<?php echo $check_climb_speed_un ?> value='1' />1&#58; Slightly
								reduced &#40;&ge; 5s to perform task&#41;</label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb_speed'
								<?php echo $check_climb_speed_deux ?> value='2' />2&#58;
								Moderately reduced &#40;&ge; 10s to perform task&#41; </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb_speed'
								<?php echo $check_climb_speed_trois ?> value='3' />3&#58;
								Severely reduced &#40;&ge; 20s to perform task&#41; </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='climb_speed'
								<?php echo $check_climb_speed_quatre ?> value='4' />4&#58;
								Unable to climb stairs </label></td>
					</tr> <!--<tr><td>Timing : <input type="text" style="width:40px;" name="climb_timing" value=""></td></tr>-->

					<tr>
						<td><br> <b>6&#41; Arising from chair <br />Patient attempts to
								arise from a straight&minus;back wood or metal chair with arms
								folded across chest
						</b></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='rise'
								<?php echo $check_rise_zero ?> value='0' />0&#58; Normal </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='rise'
								<?php echo $check_rise_un ?> value='1' />1&#58; Slow, or may
								need more than one attempt. </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='rise'
								<?php echo $check_rise_deux ?> value='2' />2&#58; Pushes self up
								from arms of seat. </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='rise'
								<?php echo $check_rise_trois ?> value='3' />3&#58; Tends to fall
								back and may have to try more than one time but can get up
								without help. </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='rise'
								<?php echo $check_rise_quatre ?> value='4' />4&#58; Unable to
								arise without help. </label></td>
					</tr>

					<tr>
						<td><br> <b>7&#41; Spasticity &minus;hip adductor muscles
								&#40;Modified Ashworth scale&#41; <br />Score more severely
								affected side
						</b></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_hip'
								<?php echo $check_spas_hip_zero ?> value='0' />0&#58; No
								increase in muscle tone </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_hip'
								<?php echo $check_spas_hip_un ?> value='1' />1&#58; Slight
								increase in muscle tone, manifested by a catch and release </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_hip'
								<?php echo $check_spas_hip_deux ?> value='2' />2&#58; More
								marked increase in muscle tone through most of the range of
								motion </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_hip'
								<?php echo $check_spas_hip_trois ?> value='3' />3&#58;
								Considerable increase in muscle tone &minus; passive movement is
								difficult </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_hip'
								<?php echo $check_spas_hip_quatre ?> value='4' />4&#58; Limb
								stiff in adduction </label></td>
					</tr>


					<tr>
						<td><br> <b>8&#41; Spasticity &minus;knee flexion &#40;Modified
								Ashworth scale&#41; <br />Score more severely affected side
						</b></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_knee'
								<?php echo $check_spas_knee_zero ?> value='0' />0&#58; No
								increase in muscle tone </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_knee'
								<?php echo $check_spas_knee_un ?> value='1' />1&#58; Slight
								increase in muscle tone, manifested by a catch and release </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_knee'
								<?php echo $check_spas_knee_deux ?> value='2' />2&#58; More
								marked increase in muscle tone through most of the range of
								motion </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_knee'
								<?php echo $check_spas_knee_trois ?> value='3' />3&#58;
								Considerable increase in muscle tone &minus; passive movement is
								difficult </label></td>
					</tr>
					<tr>
						<td><label><input type='radio' name='spas_knee'
								<?php echo $check_spas_knee_quatre ?> value='4' />4&#58; Limb
								stiff in flexion or extension </label></td>
					</tr>

					<tr>
						<td><br> <b>9&#41; Weakness &minus;hip abduction &#40;Medical
								Research Council 1976&#41;
								<tr>
									<td><label><input type='radio' name='weakness_hip'
											<?php echo $check_weakness_hip_zero ?> value='0' />0&#58; No
											weakness </label></td>
								</tr>
								<tr>
									<td><label><input type='radio' name='weakness_hip'
											<?php echo $check_weakness_hip_un ?> value='1' />1&#58; Mild
											weakness &#40;4&frasl; 5&#41; </label></td>
								</tr>
								<tr>
									<td><label><input type='radio' name='weakness_hip'
											<?php echo $check_weakness_hip_deux ?> value='2' />2&#58;
											Moderate weakness &#40;3&frasl; 5&#41; </label></td>
								</tr>
								<tr>
									<td><label><input type='radio' name='weakness_hip'
											<?php echo $check_weakness_hip_trois ?> value='3' />3&#58;
											Severe weakness &#40;1&minus;2&frasl; 5&#41; </label></td>
								</tr>
								<tr>
									<td><label><input type='radio' name='weakness_hip'
											<?php echo $check_weakness_hip_quatre ?> value='4' />4&#58;
											Plegia &#40;0&frasl; 5&#41; </label></td>
								</tr>

								<tr>
									<td><br> <b>10&#41; Weakness &minus;foot dorsiflexion
											&#40;Medical Research Council 1976&#41;
											<tr>
												<td><label><input type='radio' name='weakness_foot'
														<?php echo $check_weakness_foot_zero ?> value='0' />0&#58;
														No weakness </label></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='weakness_foot'
														<?php echo $check_weakness_foot_un ?> value='1' />1&#58;
														Mild weakness &#40;4&frasl; 5&#41; </label></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='weakness_foot'
														<?php echo $check_weakness_foot_deux ?> value='2' />2&#58;
														Moderate weakness &#40;3&frasl; 5&#41; </label></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='weakness_foot'
														<?php echo $check_weakness_foot_trois ?> value='3' />3&#58;
														Severe weakness &#40;1&minus;2&frasl; 5&#41; </label></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='weakness_foot'
														<?php echo $check_weakness_foot_quatre ?> value='4' />4&#58;
														Plegia &#40;0&frasl; 5&#41; </label></td>
											</tr>

											<tr>
												<td><br> <b>11&#41; Contractures of lower limbs <br />Score
														in supine position Hip extension&#58; lumbar spine and
														thighs touch the underlay. Hip abduction&#58; abduction up
														to an angle of &#155; 60&deg; between the legs possible
														Knee extension&#58; thigh and calf touch the underlay
														Ankle dorsal extension&#58; &#155; 10&deg; possible. Ankle
														pronation&#58; &#155; 10&deg; possible
												</b></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='lowerlimbs'
														<?php echo $check_lowerlimbs_zero ?> value='0' />0&#58; No
														contracture</label></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='lowerlimbs'
														<?php echo $check_lowerlimbs_un ?> value='1' />1&#58;
														Mild, not fixed abnormal position of one joint
														&#40;unilaterally or bilaterally&#41; </label></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='lowerlimbs'
														<?php echo $check_lowerlimbs_deux ?> value='2' />2&#58;
														Fixed contracture of one joint &#40;unilaterally or
														bilaterally&#41; </label></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='lowerlimbs'
														<?php echo $check_lowerlimbs_trois ?> value='3' />3&#58;
														Fixed contracture of two joints &#40;unilaterally or
														bilaterally&#41;</label></td>
											</tr>
											<tr>
												<td><label><input type='radio' name='lowerlimbs'
														<?php echo $check_lowerlimbs_quatre ?> value='4' />4&#58;
														Fixed contracture of more than two joints
														&#40;unilaterally or bilaterally&#41; </label></td>
											</tr>

											<tr>
												<td><br> <b>12&#41; Pain due to SP related symptoms
														<tr>
															<td><label><input type='radio' name='relatedsymptoms'
																	<?php echo $check_relatedsymptoms_zero ?> value='0' />0&#58;
																	None </label></td>
														</tr>
														<tr>
															<td><label><input type='radio' name='relatedsymptoms'
																	<?php echo $check_relatedsymptoms_un ?> value='1' />1&#58;
																	&le; 50&#37; of waking day present AND intensity 0
																	&minus; 3 points on visual analogue scale </label></td>
														</tr>
														<tr>
															<td><label><input type='radio' name='relatedsymptoms'
																	<?php echo $check_relatedsymptoms_deux ?> value='2' />2&#58;
																	&le; 50&#37; of waking day present AND intensity 4
																	&minus; 10 points on visual analogue scale </label></td>
														</tr>
														<tr>
															<td><label><input type='radio' name='relatedsymptoms'
																	<?php echo $check_relatedsymptoms_trois ?> value='3' />3&#58;
																	&#155; 50&#37; of waking day present AND intensity 0
																	&minus; 3 on visual analogue scale</label></td>
														</tr>
														<tr>
															<td><label><input type='radio' name='relatedsymptoms'
																	<?php echo $check_relatedsymptoms_quatre ?> value='4' />4&#58;
																	&#155; 50&#37; of waking day present AND intensity 4
																	&minus; 10 points on visual analogue scale</label></td>
														</tr>

														<tr>
															<td><br> <b>13&#41; Bladder and bowel function
																	<tr>
																		<td><label><input type='radio' name='BBfunction'
																				<?php echo $check_BBfunction_zero ?> value='0' />0&#58;
																				Normal bladder and bowel function </label></td>
																	</tr>
																	<tr>
																		<td><label><input type='radio' name='BBfunction'
																				<?php echo $check_BBfunction_un ?> value='1' />1&#58;
																				Urinary or fecal urgency &#40;difficulties to reach
																				toilet in time&#41; </label></td>
																	</tr>
																	<tr>
																		<td><label><input type='radio' name='BBfunction'
																				<?php echo $check_BBfunction_deux ?> value='2' />2&#58;
																				Rare and mild urge incontinence &#40;no nappy
																				required&#41; </label></td>
																	</tr>
																	<tr>
																		<td><label><input type='radio' name='BBfunction'
																				<?php echo $check_BBfunction_trois ?> value='3' />3&#58;
																				Moderate urge incontinence &#40;requires nappy or
																				catheter when out of the house&#41; </label></td>
																	</tr>
																	<tr>
																		<td><label><input type='radio' name='BBfunction'
																				<?php echo $check_BBfunction_quatre ?> value='4' />4&#58;
																				Permanent catheterization or permanent nappy </label></td>
																	</tr>


																	<tr>
																		<td colspan="2"><input type='submit' value='Submit' /></td></td>
														</tr>
	
	</table>
</form>

<?php
}

include ("../footer.php");

?>
